Be as you wish to seem: tragedy, triumphalism, and toxicity in maternity services
Authors: Elizabeth Anne Sutton, Harsha Ananthram, Nadine Montgomery, Rebecca Matthews
Journal: The Lancet Global Health (2022)

Women aspire to positive birth experiences and expect a live baby in their arms at the end of this process. In their Comment, Hannah Dahlen and colleagues (July, 2022)1Dahlen H Drandic D Shah N Cadee F Malata A Supporting midwifery is the answer to the wicked problems in maternity care.Lancet Glob Health. 2022; 10: e951-e952Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar proclaim that women are so poorly served by current models that the aspirations of birthing women have been “set at immediate survival”. The 2022 Ockenden report highlighted that a fixation on reducing the number of caesarean sections meant that survival was more than what many women could expect. Over 200 babies and nine women served by maternity services at the Shrewsbury and Telford Hospital National Health System Trust in the UK died from systemic failures that included insufficient staff training, inadequate monitoring, poor working cultures, and an organisational drive to reduce the number of caesarean births underpinned by a truculent ideology of normal birth. The “bad system” dismissed by Dahlen and colleagues1Dahlen H Drandic D Shah N Cadee F Malata A Supporting midwifery is the answer to the wicked problems in maternity care.Lancet Glob Health. 2022; 10: e951-e952Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar shows how a trust held up as a “beacon of excellence” for its “unusually low” caesarean rate can end up as a cautionary tale on failed regulation.2Ananthram H Vangaveti V Rane A Have we lost sight of the women? An observational study about normality-centred care in Australian maternity services.Aust N Z J Obstet Gynaecol. 2022; 62: 40-46Crossref PubMed Scopus (5) Google Scholar The authors blame “sensationalised media” as one reason that midwives have become “demoralised”.1Dahlen H Drandic D Shah N Cadee F Malata A Supporting midwifery is the answer to the wicked problems in maternity care.Lancet Glob Health. 2022; 10: e951-e952Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar First and foremost, the failings at Shrewsbury and Telford must always focus on the women and families who lost loved ones. Blaming an amorphous media trivialises their grief and remarkable fight for justice. Crucially, this blame exposes a fundamental reluctance to understand and to learn lessons from this tragedy. Despite evidence to the contrary,3Robson SJ Costa CM Thirty years of the World Health Organization's target caesarean section rate: time to move on.Med J Aust. 2017; 206: 181-185Crossref PubMed Scopus (30) Google Scholar, 4Ananthram H Rane A Head in the sand: contemporary Australian attitudes towards induction of labour.Aust N Z J Obstet Gynaecol. 2022; (published online March 15.)https://doi.org/10.1111/ajo.13512Crossref Scopus (1) Google Scholar Dahlen and colleagues’ stance suggests that interventions that are not medically indicated impinge on the personal autonomy of birthing women, and that more midwives will remedy these “wicked problems”.1Dahlen H Drandic D Shah N Cadee F Malata A Supporting midwifery is the answer to the wicked problems in maternity care.Lancet Glob Health. 2022; 10: e951-e952Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Furthermore, the authors’ solution to systemic failures is midwifery continuity of care. The authors do not mention that the evidence for this model is, at times, weak.5Lintern S Revealed: women and babies at risk at hospital where doctors are censored and midwives fear working.https://www.independent.co.uk/news/health/maternity-safety-nhs-babies-worcester-b1835323.htmlDate: April 30, 2021Date accessed: June 17, 2022Google Scholar The historical dog whistling, invoked by “wicked”, is an imprudent call to arms against the immediate suspension of continuity models, as recommended by the Ockenden report. Denying maternal choice for intervention means that the informed consent processes, where vaginal birth is promoted, will fail to meet the legally required standard set by the Montgomery judgment. If the definition of a midwife includes “the promotion and advocacy for non-intervention in childbirth”,2Ananthram H Vangaveti V Rane A Have we lost sight of the women? An observational study about normality-centred care in Australian maternity services.Aust N Z J Obstet Gynaecol. 2022; 62: 40-46Crossref PubMed Scopus (5) Google Scholar does this skewed advocacy not limit a birthing woman's autonomy? To enable fully informed consent, midwives must meet their legal requirements to share birth information, in all its forms. To be with the woman, they must accept the woman for all of her choices. Truthfulness to enable informed consent relies on disclosure unaffected by ideology; it requires moral rightness. If childbirth as a cultural process is to improve for women, it will need to start with clinicians reflecting on the multiple tragedies within maternity care in the UK and embracing Socrates’ wisdom to “be as you wish to seem”. We declare no competing interests. Supporting midwifery is the answer to the wicked problems in maternity careThe film Don’t Look Up, examines what it will take to get world leaders and the public to be proactive about a comet that is on a collision course with earth. We argue that the same attitude of self-interested denialism is stopping crucial action being taken when it comes to supporting midwifery models of care to address the current problems in maternity care. Full-Text PDF Open AccessBe as you wish to seem: tragedy, triumphalism, and toxicity in maternity services – Authors' replyWe thank Elizabeth Sutton and colleagues for their letter emphasising that survival is the fundamental expectation of women during childbirth. Our argument is that, in designing a better system, we should aim higher. Women clearly also have goals other than emerging from childbirth unscathed. Ideally, care should be supportive, affirming, and empowering. We do not contest the Ockenden report, which clearly shows a betrayal of safety among the UK National Health Service Trust involved. We believe that the public discourse, including media reporting, would benefit from a more holistic and global perspective rather than castigating the midwifery profession, especially considering the global shortage of midwives and the potential impact this has on the lives of women and babies. Full-Text PDF Open Access